Claims management OfficerI | SHA/212/2025

Deadline: Nov. 18, 2025, 6 p.m.

Minimum Qualifications:Bachelors Degree
Job Term:Permanent and Pensionable
Position Level:SHA 7
Number of positions:1
Qualifications, Skills and Experience Required:
For appointment to this grade, an officer must have:

Entry Grade for Claims Management-Medical Review

Bachelor’s Degree in Medicine and Surgery from a recognized institution;

Membership to the relevant professional body and in good standing;

A valid practicing license;

Proficiency in computer applications. and

Shown merit and ability as reflected in work performance and results.

Responsibilities:
You will be responsible for reviewing, processing, and validating medical claims, appraising claims based on benefit packages, issuing pre-authorizations, and undertaking quality assurance surveillance.

Officers in this cadre may be deployed to any of the following functional areas:-

Claims Management (Medical Review)

Claims Management

County Coordination (Quality Assurance and Surveillance)

Claims Management (Medical Review)

This is the entry and training grade for officers in Claims Management-Medical Review. An officer at this level will work under the guidance of a senior officer.

Key Responsibilities

Carrying out the medical reviews of medical reports;

Carrying out the reviewing, processing, and validating of medical claims from healthcare providers and healthcare facilities under supervision;

Assisting in the appraisal of medical claims based on the benefit package to determine eligibility and prevent misuse;

Implementing the issuance of pre-authorizations for access to healthcare services based on the benefit package while ensuring compliance with procedures;

Assisting in the operationalization of an e-claims management system to facilitate accurate and efficient claims processing;

Collecting and analyzing data for purposes of claim management to enhance efficiency in claims processing; and

Supporting the sensitization of claimants on the consequences of submitting false and fraudulent claims to reduce fraudulent activities.

Claims Management

Key Responsibilities

Carrying out the reviewing, processing, and validating of medical claims from healthcare providers and healthcare facilities under supervision;

Assisting in the appraisal of medical claims based on the benefit package to determine eligibility and prevent misuse;

Implementing the issuance of pre-authorizations for access to healthcare services based on the benefit package while ensuring compliance with procedures;

Assisting in the operationalization of an e-claims management system to facilitate accurate and efficient claims processing;

Collecting and analyzing data for purposes of claim management to enhance efficiency in claims processing; and

Supporting the sensitization of claimants on the consequences of submitting false and fraudulent claims to reduce fraudulent activities.

Quality Assurance and Surveillance

Key Responsibilities

Undertaking quality assurance surveillance in respect of claims to detect errors and inconsistencies;

Assisting in implementing systems and controls for detecting and identifying fraud appropriate to the Authority’s exposure and vulnerability;

Supporting the sensitization of claimants on the consequences of submitting false and fraudulent claims to reduce fraudulent activities;

Undertaking compliance monitoring and quality assurance activities in assigned regions.

Supervise clinical audits and develop corrective action plans for non-compliance.

Coordinating the implementation of Hospital Quality Improvement Teams (HQITs);

Monitoring benefit utilization and accessibility trends within the region; and

Developing detailed reports on compliance trends and recommend strategic interventions.

• Carrying out the medical reviews of medical reports;
• Carrying out the reviewing, processing, and validating of medical claims from healthcare providers and healthcare facilities under supervision;
• Assisting in the appraisal of medical claims based on the benefit package to determine eligibility and prevent misuse;
• Implementing the issuance of pre-authorizations for access to healthcare services based on the benefit package while ensuring compliance with procedures;
• Assisting in the operationalization of an e-claims management system to facilitate accurate and efficient claims processing;
• Collecting and analyzing data for purposes of claim management to enhance efficiency in claims processing;
• Supporting the sensitization of claimants on the consequences of submitting false and fraudulent claims to reduce fraudulent activities.

• Bachelor’s Degree in Medicine and Surgery
• Membership to the relevant professional body and in good standing
• A valid practicing license
• Proficiency in computer applications

• Bachelor’s Degree in Medicine and Surgery from a recognized institution
• Membership to the relevant professional body and in good standing
• A valid practicing license
• Proficiency in computer applications
• Shown merit and ability as reflected in work performance and results